Addressing the 1 Percent

Nov 01, 2012

An interview with Jeffrey C. Brenner, MD

So-called superusers, who bounce in and out of the hospital, account for 30 percent of health expenditures. The fix for this vexing challenge requires nothing less than a redesign of the way America delivers health care, says a physician turned community activist.

Of the 79,000 residents in Camden, N.J., 386 constitute the top 1 percent of emergency department (ED) visitors. In 2011, they made a total of 5,000 trips to one of the city's three EDs for an average of 13 visits per patient.

Nearly 80 percent of those ED patients visited more than one hospital during the year-and inpatient high-utilizers are just as transient. "They are highly mobile, and they go from ED to ED, hospital to hospital, in search of better care," says Jeffrey C. Brenner, MD, executive director and medical director of the Camden Coalition of Healthcare Providers.

To address the issue, all three Camden hospitals now send information about every ED visit and inpatient admission-patient names, addresses, insurance type, and more-to a database that Brenner created. He and his team scour the data to identify community members who had more than two inpatient stays in the last six months. Then they enroll these superusers in a citywide care management service, which works with all of the providers in Camden to ensure these patients get needed primary care, behavioral health, and social services so they are less likely to need costly inpatient care.

So far, the results are mixed. "We do not always hit a home run because these are very difficult patients," Brenner says. "We score with some, and some are much more challenging."

What Success Looks Like

Here's what a home run looks like. Last November, a 55-year-old man with nine chronic conditions was admitted to a Camden hospital and assigned to a care manager at Camden Coalition, which runs the care management program. In the previous year, the patient visited the ED nine times and had six inpatient stays, racking up total charges of $312,000. He is a dual-eligible covered by Medicare and Medicaid, which paid a total of $59,000 for that care.

"We coordinated his home care, transport, meals, crutches, wheelchair, and dialysis. We got him to see a nephrologist, got him on the transplant list, and arranged numerous other services," says Brenner. In the six months after the 55-year-old patient "graduated" from care coordination, he had had no ED visits and no hospitalizations.

A Virtual Organization

Case management for superusers is just one of several ways that the Camden Coalition carries out its mission statement: to improve the health status of Camden residents by increasing the capacity, quality, and access of health care. Other initiatives include helping establish a medical clinic in an apartment building where a high concentration of superusers live and forming a citywide diabetes collaborative to help primary care practices improve health outcomes for patients with diabetes.

Organized as a not-for-profit agency, the Coalition gathers providers, social service agencies, churches, and other constituencies to work together on some of healthcare's thorniest problems. Representatives from all of these entities serve on the Coalition's board.

Brenner refers to the Coalition as a virtual organization because it has no employees. Rather, all of its staff members are employed by Cooper University Hospital and leased to the Coalition.

The Coalition's philanthropic grant funds are administered by Cooper's foundation. "In addition, other hospitals in the region who have representatives on our board contribute money to our upkeep," Brenner says. "These are highly, highly competitive hospitals that are all working together toward the same goals."

This type of collaboration among providers is necessary to achieve the type of change required. "Entirely new models of how we deliver care are going to have to be designed-and the institutions that don't figure that out are going to be like Kodak and Blockbuster. They're going to be history," Brenner says. "The next 30 years are going to be about sucking cost out of the system, and if you don't figure out how to be a player in that, you're not going to be relevant."

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